Provider Demographics
NPI:1316924293
Name:RYAN, SUSAN W
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:W
Last Name:RYAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:W
Other - Last Name:RYAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:PO BOX 173862
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80217-3862
Mailing Address - Country:US
Mailing Address - Phone:303-306-7783
Mailing Address - Fax:303-306-7753
Practice Address - Street 1:4567 E. 9TH AVENUE
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80220-5337
Practice Address - Country:US
Practice Address - Phone:303-320-2455
Practice Address - Fax:303-306-7753
Is Sole Proprietor?:No
Enumeration Date:2005-12-30
Last Update Date:2015-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO31296207P00000X
CODR.0031296207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01312966Medicaid
COF32896Medicare UPIN
CO01312966Medicaid